A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Use a cuff with a width that is about 60% of the client's arm circumference.

Release the pressure on the client's arm 5 to 6 mm per second.

Apply the cuff above the client's antecubital fossa

Have the client sit with his arm resting above the level of his heart.

Answer and Explanation

Correct Answer : A,B

A cuff that is too narrow or too wide can result in inaccurate blood pressure readings. The cuff should be snug but not tight and cover about 80% of the arm length. The pressure should be released at a rate of 2 to 3 mm per second to avoid missing auscultatory gaps or causing discomfort to the client.

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Correct Answer is A

Explanation

A tracheostomy is a surgical opening in the neck that allows air to enter the lungs through a tube called a tracheostomy tube. The tube has two parts: an outer cannula that stays in place and an inner cannula that can be removed for cleaning. The tracheostomy ties are used to secure the tube to the neck and prevent it from falling out. They should be adjusted to allow one finger to fit snugly underneath, so that they are not too tight or too loose.

A. Secure restraints to allow three fingers to slide under the restraints. B. Assess skin temperature and color before applying the restraints. C. Ensure that the client's bed is in the lowest position. D. Attach the client's restraints to the bed rail. E. Pad bony prominences before applying the restraints.

Correct Answer is ["A","B","E"]

Explanation

The nurse should secure restraints to allow three fingers to slide under the restraints to prevent circulation impairment and nerve damage. The nurse should also assess skin temperature and color before applying the restraints to establish a baseline and monitor for signs of ischemia. The nurse should ensure that the client's bed is in the lowest position to reduce the risk of injury from falls. The nurse should pad bony prominences before applying the restraints to prevent skin breakdown and pressure ulcers. The nurse should not attach the client's restraints to the bed rail because this can cause injury if the bed is moved or adjusted. The nurse should attach the restraints to a part of the bed frame that moves with the client, such as the mattress support platform.

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A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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